Apply for emergency assistance review
Use the official JIT-EX intake form below to submit your request for review.
Before you apply
- Current bill, shutoff notice, or statement
- Provider, landlord, pharmacy, or service name
- Amount due and due date
- Current contact information
- Short explanation of hardship
- City of residence in Cook County
Submitting a request does not guarantee approval, payment, or eligibility.
Application intake
If the embedded form does not load on your device, use the button to open the application in a separate tab.
Embedded intake form is connected to your live Google Form.
Incomplete or inaccurate information may delay review.